Discharge Planner

About Company:

We’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.

Read more here: https://ow.ly/YQ1C50WuRH1

This certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

Our benefits include:

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.

• Generous PTO – A robust paid time off policy to support work-life balance.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

At Bradford Health Services, we don’t just invest in our patients—we invest in our people.

About the Role:

The Discharge Planner plays a critical role in coordinating and facilitating the safe and efficient transition of patients with substance use and co-occurring mental health disorders. This position ensures that each patient’s discharge plan is comprehensive, addressing medical, social, and emotional needs to promote optimal recovery and prevent readmissions. The Discharge Planner collaborates closely with multidisciplinary teams, including medical staff, social workers, and community resources, to develop individualized care plans that comply with Medicaid and other regulatory requirements. By managing complex cases involving dialysis, long-term care, and mental health considerations, the Discharge Planner supports patients and their families through education and resource linkage. Ultimately, this role enhances patient outcomes by ensuring continuity of care and access to necessary services after discharge.

Minimum Qualifications:

• Bachelor’s degree in Social Work, Nursing, Healthcare Administration, or a related field.
• Experience in discharge planning or case management within a healthcare setting.
• Knowledge of Medicaid policies and procedures related to patient discharge.
• Familiarity with long-term care services, dialysis treatment protocols, and mental health resources.
• Strong organizational and communication skills with the ability to manage multiple complex cases.

Preferred Qualifications:

• Master’s degree in Social Work (MSW) or related healthcare discipline.
• Certification in Case Management (CCM) or Discharge Planning.
• Experience working with diverse patient populations and community-based social services.
• Training in emotional stability techniques and crisis intervention.
• Proficiency with electronic health records (EHR) and discharge planning software.

Responsibilities:

• Provides holistic and comprehensive case management services to all clients including intake assessment, biopsychosocial assessment, ASAM, utilization reviews, goal setting, and weekly progress monitoring
• Acts as an initial contact for each new client
• Responsible for ensuring timely completion of client orientation pack
• Responsible for ensuring client has resources and knowledge to progress through program and towards resolution of treatment plan goals
• Assists with vacation coverage of caseloads and groups for Primary Therapists as needed
• Facilitates psychoeducational groups as directed and attends clinical groups as needed
• Assists guides and therapists as needed
• Maintains an active case management caseload, providing interventions as needed and within area of expertise and limits of credentials
• Works with the client on a day-to-day basis assessing client needs and acting as a client advocate
• Provides crisis management for clients; makes linkages for interventions as appropriate
• Maintains client and program records in accordance with applicable standards and regulations of Licensure and Accreditation Boards
• Maintains and updates client release of information to third parties
• Provides aftercare calls for clients as directed by the Primary Therapist
• Meets each client weekly for a one-on-one assessment and documents meeting in EMR
• Attends clinical meetings and meets regularly with supervisor to exchange pertinent information and receive supervision
• Works in collaboration with other professionals as part of a treatment team to ensure optimum client outcomes
• Develop and maintain relationships with referring professionals
• Acts as client liaisons regarding medical needs and collaborates with the medical department/ professionals in implementing treatment plans
• Assists Primary Therapist with aftercare needs and connecting with legal authorities as direct by the Primary Therapist
• Manages client graduation/discharge process

Skills:

The required skills such as discharge planning, Medicaid knowledge, and case management are essential for developing and implementing effective patient transition plans that meet regulatory standards and individual needs. Expertise in dialysis and long-term care enables the Discharge Planner to coordinate specialized medical services and ensure continuity of care. Social services and mental health skills are applied daily to assess psychosocial factors and connect patients with appropriate community resources, enhancing overall well-being. Emotional stability is critical for managing sensitive situations and providing compassionate support to patients and families during stressful transitions. Together, these skills facilitate comprehensive medical management and collaborative teamwork, resulting in improved patient outcomes and reduced hospital readmissions.